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AN ANNOUNCEMENT FROM ALLEN & HANBURYS
In January 2009 Allen & Hanburys launched Avamys®T (fluticasone furoate), an intra-nasal
steroid (INS) for treatment of the symptoms of allergic rhinitis. 1 Avamys (fluticasone furoate) is a different
chemical entity to Flixonase® (fluticasone propionate) and is therefore a distinct drug molecule and not
a salt or a prodrug of fluticasone propionate. 2
A survey taken in May 2009, amongst 128 pharmacists showed that: 3
• 31% were unaware of this INS (Avamys, fluticasone furoate).
• 63% were not aware of the differences between fluticasone furoate and fluticasone propionate.
Allen & Hanburys would like to highlight the important key differences that will support you in dispensing
the right medicine.
fluticasone propionate 4 ' 5
Dose per spray
Sprays per pack
6 years and older
4 years and older
Cost (on prescription)
In a single dose study comparing Avamys to fluticasone propionate nasal spray, patients preferred
Avamys over fluticasone propionate based on sensory attributes. 6 Avamys provides relief from both
nasal and ocular symptoms in an advanced device. 710 Avamys is available to purchase from AAH and
(Please refer lo the full Summary of Product Characteristics before
Avamys' T Nasal Spray Suspension
(fluticasone furoate 27.5 micrograms/metered spray)
Uses: Treatment of symptoms of allergic rhinitis in adults and
children aged 6 years and over. Dosage and Administration:
For intranasal use only. Adulls: Two sprays per nostril once daily
(total daily dose, 110 micrograms). Once symptoms controlled, use
maintenance dose of one spray per nostnl once daily (total daily
dose, 55 micrograms). Reduce to lowest dose at which effective
control of symptoms is maintained. Children aged 6 to 11 years
One spray per nostnl once daily (total daily dose, 55 micrograms)
If patient is not adequately responding, increase daily dose to
1 10 micrograms (two sprays per nostril, once daily) and reduce
back down to 55 microgram daily dose once control is achieved.
Contraindication: Hypersensitivity to active substance or
excipients. Side Effects: Systemic effects of nasal corticosteroids
may occur, particularly when prescribed at high doses for prolonged
periods Very common epistaxis. Epistaxis was generally mild lo
moderate, with incidences in adulls and adolescents higher in
longer-term use (more than 6 weeks). Common: nasal ulceration.
Rare hypersensitivity reactions including anaphylaxis, angioedema,
rash, and urticaria. Precautions: Treatment with higher than
recommended doses of nasal corticosteroids may result in clinically
significant adrenal suppression. Consider additional systemic
corticosteroid cover during periods of stress or elective surgery.
Caution when prescribing concurrently with other corticosteroids
1 . Avamys Summary of Product Characteristics 2009.
2 Salter M, Biggadike K, Matthews JL et al. Am J Physiol Lung Cell Mol Physiol 2007; 293: 660-667
3 GlaxoSmithKline Data on File AVS/DOF/09/42575/1 .
4. MIMS (Monthly Index of Medical Specialities). Online, last accessed date April 2010.
5 Flixonase Summary of Product Characteristics 2010.
Growth retardation has been reported in children receiving some
nasal corticosteroids at licensed doses. Monitor height of children.
Consider referring to a paedialric specialist. May cause irritation of
the nasal mucosa Caution when treating patients with severe liver
disease, systemic exposure likely to be increased. Nasal and
inhaled corticosteroids may result in the development of glaucoma
and/or cataracts Close monitoring is warranted in patients with a
change in vision or with a history of increased intraocular pressure,
glaucoma and/or cataracts. Pregnancy and Lactation:
No adequate data available Recommended nasal doses result in
minimal systemic exposure. It is unknown if fluticasone furoate
nasal spray is excreted in breast milk. Only use if the expected
benefits to the mother outweigh the possible risks to the foetus or
child. Drug interactions: Caution is recommended when co-
administering with inhibitors of the cytochrome P450 3A4 system,
e.g. ketoconazole and ritonavir Presentation and Basic NHS
cost: Avamys Nasal Spray Suspension. 120 sprays: £6.44
Marketing Authorisation Number: EU/1/07/434/003. Legal
category: POM PL holder: Glaxo Group Ltd, Greentord,
Middlesex, UB6 ONN, United Kingdom Last date of revision:
Adverse events should be reported. Reporting forms and
information can be found at www.yellowcard.gov.uk. Adverse
events should also be reported to GlaxoSmithKline on
0800 221 441.
Avamys is a n
trademark of the GlaxoSmithKline group of
Avoid concomitant administration of inhibitors of the
cytochrome P450 3A4 system, e.g ketoconazole, and ritonavir.
Pregnancy and lactation: Clinical data is not available. Balance
risks against benefits. Side effects: Very common: Epistaxis.
Common: Headache, unpleasant taste, unpleasant smell, nasal
dryness, nasal irritation, throat dryness, throat irritation. Very
rare: Cutaneous hypersensitivity reactions, angioedema,
bronchospasm, anaphylactic reactions, glaucoma, raised
intraocular pressure, cataract, nasal septal perforation.
Presentation and Basic NHS cost: Flixonase Aqueous Nasal
Spray: 150 metered sprays - £11.01 Market Authorisation
Number: PL 10949/0036. Market Authorisation Holder: Glaxo
Wellcome UK Limited trading as Allen & Hanburys, Stockley Park
West, Middlesex, UB11 1BT. Legal category: POM. Date of
preparation: January 2010.
(Please refer to the full Summary of Producl Characteristics
Flixonase 8 ' Aqueous Nasal Spray
(fluticasone propionate 50 micrograms/metered spray)
Uses: Prophylaxis and treatment of seasonal allergic and
perennial rhinitis in adults and children aged 4 years and over
Dosage and administration: For intranasal use only. Adulls: Two
sprays per nostril once daily in the morning. Once symptoms
controlled, use maintenance dose of one spray per nostril once
daily. Two sprays per nostril twice daily may be required
Maximum daily dose four sprays per nostril. Children aged 4 to 11
years: One spray per nostril once daily in the morning. One spray
per nostril twice daily may be required. Maximum daily dose two
sprays per nostril For full therapeutic benefit regular usage is
essential. The minimum dose should be used at which effective
control of symptoms is maintained. Contra-indication:
Hypersensitivity to any of its ingredients Precautions: Local
infections should be appropriately treated. Caution when
transferring patients from systemic steroids. Systemic effects of
nasal corticosteroids may occur at high doses for prolonged
periods. Growth retardation has been reported in children
receiving some nasal corticosteroids at licensed doses. Monitor
height of children. In addition, consider referring patients to a
paediatric specialist Treatment with higher than recommended
doses of nasal corticosteroids may result in clinically significant
adrenal suppression. Consider additional systemic corticosteroid
cover during periods of stress or elective surgery.
6 Meltzer E, Stahlman J ef al. Clin Ther 2008; 30: 271-9.
7 Fokkens WJ, Jogi R, Relnartz S el al. Allergy 2007; 62: 1078-1084.
8. Kaiser HB, Nacleno RM, Given J et al. J Allergy Clin Immunol 2007; 119(6): 1430-1437.
9. Jacobs R, Martin B, Hampel F et al. Curr Med Res Opin 2009; 25: 1393-1401.
10. Berger WE, Godfrey JW, Slater AL. ExperOpin Drug Deliv. 2007; 4(6): 689-701.
Adverse events should be reported. Reporting forms and
information can be found at www.yellowcard.gov.uk. Adverse
events should also be reported to GlaxoSmithKline on
0800 221 441.
Flixonase is a registered trademark of the GlaxoSmithKline group
ALLEN 8. HANBURYS
For more information on Avamys visit www.eyesandnoses.co.uk
Date of Preparation: May 2010 UK/FF/0070/10
Have your say
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i ELIZABETH LEE,
NOW WORKS AS
A CLEANER FOR A
THAT SEEMS A
TRAGIC LOSS 5
The first tears came as the Court of
Appeal heard how Carmel Shelter
had collapsed after taking
propranolol instead of the
prednisolone prescribed. Elizabeth
Lee dabbed her eyes, lent into her
father for comfort, and probably
wished for the billionth time that she
could have put the clock back to
It was then that a diligent,
20-something pharmacist handed
out a prescription for beta blockers
instead of steroids. It had been a
long shift, she momentarily slipped
beneath her own high standards, and
she made a mistake
Of course you feel for Ms Shelter's
family. Ms Lee's mistake can't be
brushed aside and forgotten about.
A grandmother's health suffered
as a result and she later died - of
an underlying condition and not
If that was my grandmother or
yours we would feel angry and want
Justice. But my overriding sentiment
after attending Ms Lee's Court of
Appeal hearing last week is that
justice hasn't really been served.
Everything indicates Ms Lee is an
exceptionally honest and dignified
person. She quit as a pharmacist as
soon as her error came to light. She
has shunned the limelight -
repeatedly stressing her desire to
pursue a quiet life. In the limited
conversations she has had with C+D
she has always spoken of her sorrow
for what she did, extended her
condolences to Ms Sheller's family
and never tried to make excuses.
One of the appeal court judges
made a telling counter attack to this
argument. He drew a parallel to
careless driving. You can be an
upstanding citizen, but if you
momentarily take your eyes off the
road and cause an accident then
you have to face the consequences.
That might be true, but what if
the accident took place on a
particularly hazardous piece of
road? Would it not be better to
tackle road safety instead of making
the driver a scapegoat?
For Ms Lee the personal cost of
this case has been vast. It was
impossible to reconcile the wan
individual who sat before the court
last week with the vibrant woman of
three years ago. In the quest to
avenge one life, another has been
destroyed. A one-time talented
pharmacist now works as a cleaner
for a local church, the court heard.
That seems a tragic loss for both
pharmacy and society as a whole
Thankfully, the Court of Appeal
offered some redemption: it quashed
Ms Lee's custodial sentence. One
avenue for prosecuting errors has
been partially plugged thanks to Ms
Lee's appeal. It's up to us to
complete the job and ensure her
legacy (p10) is as the pharmacist
who brought an end to criminal
prosecutions for dispensing errors.
Max Cosney, News Editor
6 Dispensing error talks hit "difficulties"
7 Guernsey threatens break from RPSGB
8 Script charge shake-up proposed
10 The legacy of Elizabeth Lee
13 Product and market news
14 Time for sector to make a stand
15 The Finance Zone
16 Xrayser and Terry Maguire
17 Update: Interpreting blood test results
Part 1 looks at disease management
19 Practical Approach
Complementary medicines for arthritis
20 Eye and earcare
Making the most of this £64 million market
24 Childhood constipation
What you need to know about new Nice guidelines
Improve your time management skills
© UBM Medica, Chemist + Druggist incorporating Retail Chemist, Pharmacy Update and Beauty Counter. Published Saturdays by UBM Medica, Ludgate House, 245 Blackfriars Road, London SE1 9UY C + D online at
www chemistanddruggist.co.uk. Subscriptions: With C+D Monthly pricelist £250 (Uk), without pricelist £205 (UK). ROW price £365. Circulation and subscription UBM Information Ltd, Tower House. Sovereign Park, Lathkill St,
Market Harborough, Leics. LE16 9EF. Telephone: 01858 438809 Fax. 01858 434958 Refunds on cancelled subscriptions will only be provided at the publisher's discretion, unless specifically guaranteed within the terms of
subscription offer The editorial photos used are courtesy of the suppliers whose products they feature We are not responsible for the content of any external websites referred to in this magazine All rights reserved No part of
this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including photocopying, recording or any information storage or retrieval system without the express prior written consent
of the publisher. The contents of Chemist+Druggist are subject to reproduction in information storage and retrieval systems UBM Information Ltd may pass suitable reader addresses to other relevant suppliers. If you do not wish
to receive sales information from other companies please write to Emily Miles at UBM Medica Origination by ITM Publishing Services, Central House, 142 Central St, London EC1V 8AR Printed by Headley Brothers Ltd, The Invicta
Press, Queens Road, Ashford TN24 8HH. Registered at the Post Office as a Newspaper. Volume 273 No 6750
Dispensing error protection
negotiations 'in difficulty'
EXCLUSIVE Prosecution threat remains after talks stall, Elizabeth Lee appeal court hears
Negotiations have stalled on a deal
to protect pharmacists from criminal
prosecution for one-off dispensing
errors, C+D can reveal.
Industry officials have clashed
with the Crown Prosecution Service
(CPS) over establishing the public
interest in error cases, London's
Court of Appeal heard last week.
"Difficulties have arisen in
negotiations," CPS informed the
court, when asked for an update on
the guidance during former locum
Elizabeth Lee's appeal against a
custodial sentence for a dispensing
When pushed by judges for a
revised publication date, prosecutor
John Price said: "Nothing is
imminent ... I am unable to give the
court a date. I'm instructed [by the
CPS] the parties have encountered
The setback comes despite
repeated pledges from the CPS that
the guidance was in the final stages.
Talks have taken place between
prosecutors, the MHRA and the DH.
The protection deal was first pledged
almost a year ago.
Lord Justice Aitkens, one of the
three appeal court judges in the
Elizabeth Lee case, said: "With
three parties you can imagine
Prosecutors, the MHRA and the DH have clashed over public interest in error cases
papers swirling around for months
or even years."
The CPS statement on guidance
dealt a blow to Ms Lee's defence,
according to a member of her
PDA chairman Mark Koziol said
they had hoped to nullify both
parts of the Medicines Act that
provide the platform for criminal
prosecution of pharmacists.
But because of the guidance delay,
section 64.1, which governs wrong
product supply, had to be left "to lie
on the table".
Ms Lee successfully overturned
her conviction, made under a section
85.5 labelling offence, at the
hearing. Her conviction was then
substituted for the 64.1 offence
at the prosecution's request
and resulted in a £300 fine for
The CPS was not available for
comment as C+D went to press.
The DH said interim guidance for
prosecutors had been drafted. A
spokesperson added: "The guidance
is still under discussion and will be
published once agreed."
The RPSCB urged all sides to
urgently agree a deal. Chief
executive Jeremy Holmes said:
"We really need action on this issue
to provide clarity. . . We urge the
parties to redouble their efforts."
What is the legacy of
See analysis, p10
Thanks for your
Elizabeth Lee has thanked C+D
readers for their support during
her trial and expressed her
desire to return to a "quiet and
Speaking outside the Court of
Appeal last week, the former
locum told C+D: "Bless you and
your kind words."
C+D passed on messages of
support to Ms Lee following her
conviction for a single
dispensing error last April.
Ms Lee left the Court of
Appeal in tears after judges
substituted her custodial
sentence for a £300 fine.
In a written statement she
said she was relieved at the
court's decision. A custodial
sentence had been a "difficult
burden to bear", she said.
The written statement from
Ms Lee added: "I now wish to
finally put this tragic episode
behind me and hope that I will
be allowed to return to a quiet
and normal life."
The court heard how Ms Lee
had been working as a part-time
cleaner for a local church after
choosing not to work as a
pharmacist following her error.
Read Elizabeth Lee's
statement in full at:
PSNI Statutory Committee upholds removal from register
A County Down pharmacist has had
his bid to be restored to the
pharmaceutical register refused by
the PSNI Statutory Committee.
Derek Webb of Groomsport, who
was superintendent pharmacist of
Webb's Pharmacies, had his name
removed from the register for non-
payment of fees in October 2006.
Mr Webb had applied to have his
name restored to the register in
2010. However, since he had two
convictions dating from September
2006 his application had to be
considered by the Statutory
The previous convictions related
to advertising a POM medicine and
placing on the market for sale a
relevant medicinal product that
did not have a Marketing
The inquiry was told that on
purchasing his fifth pharmacy in
December 2004, Mr Webb obtained
the rights to "The Portavogie
Teething Mixture" and he supplied
this medicine from all his
pharmacies as well as by mail order.
The teething mixture did not have
a MA and contained Trimeprazine,
a POM. Following a complaint
from the public an extensive recall
of the medicine was undertaken in
At the hearing Mr Webb accepted
that his actions had brought into
question his fitness to practise.
He argued that his absence from
the register had coincided with
a period similar to one that might
be imposed had the matter been
dealt with by the Statutory
Tim Ferris, chairman of the
Statutory Committee, told Mr Webb
that he had failed to convince the
committee that he had sufficient
insight into the seriousness of what
he had done and had not take
sufficient steps to prepare himself
for practice. Contributed
6 Chemist Druggist 05.06.10
Get news straight to your inbox
to break from RPSGB
EXCLUSIVE Island pharmacists set to form own professional body
Pharmacists on Guernsey are poised
to form their own professional body
after regulatory powers are passed
to the General Pharmaceutical
Council (GPhC), C+D can reveal.
In a letter sent to all pharmacists
in the Channel Island's bailiwick,
which also includes Alderney and
Sark, the Guernsey branch
committee has proposed to "totally
devolve [from the RPSGB] and form
a new independent group"
The move comes after growing
dissatisfaction with professional
leadership from the Society among
One Guernsey pharmacist,
who asked to remain anonymous,
said crown dependencies, which
also include Jersey and the Isle of
Man, felt "left out" of the Society's
Society director for England
Howard Duff said the Society was
"making every effort" to meet the
needs of all pharmacists in the UK.
"We value and need the contribution
of all members to build a strong
leadership body and very much hope
members in Guernsey decide to
remain with the Society," he said.
However, it would be cheaper for
pharmacists practising in the
bailiwick to band together and fly in
an expert each month to deliver a
CPD session than for them each to
pay the Society's proposed £192
membership fee, the Guernsey
A Jersey pharmacist confirmed
resentment toward the Society in
the dependencies, describing the
new body as "just trying to usurp
what the NPA is offering". However,
there were no plans for Jersey to
form its own breakaway group, the
The Society's Isle of Man branch
also confirmed its intent to remain
with the future professional
Membership of the Guernsey
breakaway body would be obligatory
for pharmacists on the islands,
numbering around 40. A fee of £10,
and £5 for retired pharmacists and
technicians, has been proposed.
A vote whether to go ahead and
form the splinter faction,
prospectively called the Guernsey
Pharmacist Group, was due to be
held on Thursday.
PNA questionnaires hit pharmacies
Some PCTs are quizzing contractors
on unnecessary commercial details
as they work to complete their
pharmaceutical needs assessments
(PNAs), PSNC has warned.
But the committee stressed
contractors should complete the
questions where they were
appropriate to the task.
PSNC said trusts were now
working "full steam ahead" to
complete their PNAs after
regulations concerning them came
into force in May. Many are sending
contractors questionnaires to help
determine current service provision
and willingness to provide services.
There have previously been
concerns that PCTs would not
have the capability to produce
effective PNAs, which will
eventually be used as the basis of
commissioning and new contract
But Steve Lutener, head of
regulation at PSNC, said much of
the feedback from LPCs so far on
PNAs had been positive
However, he warned that in some
cases the trusts had not held
detailed discussions with the
And he further cautioned that
some trusts had been asking
questions that were irrelevant,
such as the number of printers in a
pharmacy, or commercially
sensitive, such as details on staff
and their qualifications.
Mr Lutener said: "We are
encouraging completion of the
questionnaires so long as the
questions asked are appropriate and
What has your PCT
asked you about PNAs?
More than 6.3 million Britons
have given medicines to family
and friends for whom they
were not prescribed, research
by Lloydspharmacy has revealed.
The multiple has raised the
danger of passing on prescription
drugs and urged patients to
return unused medicines to their
local pharmacies to be disposed
Results of the consultation on the
GPhC's draft rules were set to be
the focus of proceedings at this
week's council meeting. Papers
from the meeting will be made
available on the Council's website:
GPhC was unable to comment on
the results of the consultation as
C+D went to press.
Pharmacies should take action to
support patients who misuse
alcohol, Nice has said. Under
new public health guidance,
pharmacists are urged to offer
structured advice on alcohol,
including highlighting potential
harms, barriers to change, and
strategies to reduce alcohol
The National Patient Safety
Agency has unveiled the 10 key
areas it aims to tackle to reduce
patient harm across the NHS.
The list includes focus on unsafe
use of insulin, anticoagulation
therapy, falls prevention and
treatment of patients with
Illegal slimming pills
A 44-year-old man has received a
six month prison sentence for
illegally selling and supplying
unlicensed slimming pills
containing ephedrine. The MHRA
said the pills had been sold online
at www.wholesalefx.co.uk as
well as via online auction sites,
and called the case "another
example of the danger of buying
any type of drug from an
Get your digest of all the day's big health news
Key role for pharmacy in
script charge shakeup
Report recommends all long-term conditions exempted from charges
Will the coalition
government be good
"I wait with baited breath and
believe the proof of the pudding is
in the eating. We have got to wait
JonThroup, Burrows & Close
"I would say yes because I think that
they will offer a new kind of politics,
and we need to give them a chance
to deliver it."
Jayne Welsh, Tesco Pharmacy,
pharmacists have little faith in the
partnership, it seems, with over
three quarters of our poll
respondents believing they have
little to offer the sector.
Next week's question:
How much longer will pharmacy be
kept waiting for CPS guidance on
dispensing errors? Vote at
A £430 million overhaul of
prescription charges in England to
make all patients with long-term
conditions exempt could see
patients registered with pharmacists.
In a review of prescription charges
for the Department of Health (DH)
published this week, Royal College of
Physicians president Ian Cilmore said
patients with conditions lasting at
least six months, including
conditions such as hypertension,
should be made exempt from
charges "as soon as possible".
The report, which DH officials saw
in November, estimates the total
cost of extending the exemption as
£430m. However, the burden could
be eased by a phased reduction in
prescription pre-payment certificates
(PPC) prices, cutting the annual cost
to just £60 by 2012-13.
To achieve this, pharmacies would
have to take the lead in helping
patients buy pre-payment
certificates, professor Cilmore said.
"This might include wider
availability of PPCs at pharmacies
and the ability to automatically
qualify for a PPC after paying the
equivalent cost through
accumulated individual prescription
charges, for example through a
loyalty mechanism (possibly using
smartcard technology) or
registration with a pharmacist."
Currently, only 1,600 pharmacies
in England are estimated to offer the
PSNC head of NHS services
Alastair Buxton was broadly
supportive of the proposed move,
but warned that it could lead to
added bureaucracy for pharmacists.
PSNC backed the abolition of all
prescription charges in England, but
understood the government's
hesitance to implement the change
due to the economic climate, Mr
DH minister Earl Howe welcomed
the report, but warned that any
decision would be taken in context
of the next NHS spending review,
which is due to report in the autumn.
Clinical debate C+D's Chris Chapman looks at the evidence behind the headlines
Statins: why familiarity must
not breed complacency
Ask any pharmacist to name the
five drugs they most commonly
dispense and you'll no doubt find a
statin on the list. But are we giving
them enough attention?
A new paper in the BMJ suggests
we aren't. The team used UK
general practice database
QResearch to gather data from
368 CP surgeries on some two
million patients. Of these, around
226,000 patients were started on
statins, most commonly
simvastatin or atorvastatin. The
team then studied a range of
adverse outcomes over six years.
They found that for every
10,000 women at high risk of CVD
treated with a statin, they would
prevent 271 cases of CVD and eight
cases of oesophageal cancer. So far,
so good. However, the data suggests
there would also be 74 extra
patients with liver dysfunction, 23
with acute renal failure, 307 with
cataracts, and 39 with myopathy.
The figures were similar in men,
who were at an even greater risk of
myopathy (110 cases) but lower risk
of cataracts (191 cases). It didn't
make much difference which statin
was prescribed in terms of adverse
reactions, although patients on
fluvastatin were at a higher risk of
liver dysfunction. These risks
persisted during treatment, but were
highest in the first year.
And this paper comes hot on the
heels of an MHRA warning of an
increased risk of myopathy at high-
dose simvastatin (80mg), based on
data from the 12,064-patient
So will there be a shift in statin
prescribing? I'm not so sure. The
risks associated with statin therapy
are well known. And, as a BMJ
editorial argues, the benefits
of therapy probably outweigh
The message for pharmacists is
simply to be watchful. No other
healthcare professional is in such
an ideal position to intervene
when it comes to adverse
reactions - particularly when it
comes to OTC simvastatin. An
MUR, or simply asking a patient
about their health, could nip any
problems in the bud.
Statins are of proven benefit
when used within guidelines. That
said, the risks of statin therapy,
like any other medicine, shouldn't
be forgotten just because the
drugs are dispensed every day.
To discuss this subject in
private with your pharmacy
colleagues, join the debate in
C+D's Linkedln group at
www.linkedin.com - search for
Chemist and Druggist.
Chat with Chris on Twitter:
of fee h?vfwsr s«»d?
Telfasl 1 20 mq film-coaled tablets
The lablets are film-coated peach coloured tablets containing 120 mg
lexolenadine hydrochloride, equivalent to 1 1 2 tog ol fexofenadine.
For relief ol symptoms associated with seasonal allergic rhinitis.
Dosage & Administration:
For the treatment ol seasonal allergic rhinitis in adults and children aged
12 years and over, the recommended dose ol lexolenadine hydrochloride
is 120 mg once daily belore a meal The etticacy and salely ol lexolenadine
hydrochloride has not been established in children under 6 years ol age.
Known hypeisensitivily lo any ol the product's ingredients
Studies in adults have shown thai il is not necessary lo adjust the dose ol
lexolenadine hydrochloride in the elderly or in renally or hepalically
impaired patients However, lexolenadine should be administered with
care in these special groups
Side effects (Please refer to the Summary ot Product
Characteristics for full side-effect details):
In controlled clinical trials the incidence ol commonly reported adverse
events observed with lexolenadine was similar lo thai observed with
placebo. These adverse events were headache, drowsiness, nausea,
dizziness, and sleep disorders or paronina. such as nightmares. In rare
cases rash, hypersensitivity reaclions with manifestations such as
angioedema. chest lightness, dyspnoea, and systemic anaphylaxis have
also been reported.
Pregnancy & Lactation:
Fexofenadine is not recommended in pregnancy or tor mothers breast-
feeding their babies, due lo absence ol experience in this group ol patients
Legal Category: POM
Marketing Authorisation Number: PL 04425/0157
NHS Price: Pack of 30 Tablets: £ 6.23
Further information is available liom Winthrop Pharmaceuticals,
One Onslow Sheet, Guildford, Surrey. GU1 4YS.
Date ot Revision of Prescribing Information: April 2009
Economise without compromise
Adverse events should be reported and information about adverse event reporting can be found on www.yellowcard.nov.uk
Adverse events should also be reported to Winthrop Pharmaceutical UK Ltd as follows:- Email: email@example.com Tel. 01483 554242 Fax.:01483 554806
For lurlher inlormalion please visit our websile www.winthrop-pharrm.co uk. freephone 0800 854431 or contact Winthrop Pharmaceuticals. 1 Onslow Street. Guildlord, Surrey. GU1 4YS Fax number 01483 554831 Date ol Preparation April 2009 STW374
C+D breaking news: get it first
The legacy of Elizabeth Lee
The former locum had the jail term she received for a dispensing error quashed last week. But
will her appeal victory keep similar cases out of the criminal courts? Max Gosney reports
For one pharmacist at least the
threat of criminal punishment for a
single dispensing error has been
lifted. Elizabeth Lee left the Court of
Appeal on May 26 with her
suspended jail sentence quashed.
The reversal will bring heady cheers
in dispensaries across the land, but
this remains a victory tinged with
But first let's take the positives.
The highest court in the land has
overturned a custodial sentence for
a dispensing error. Ms Lee was a
promising young pharmacist when
she arrived for a locum shift at a
Tesco store in Windsor in August
2007. Later that day she supplied
propanolol instead of the prescribed
prednisolone to cancer patient
Carmel Shelter, who later died.
The mistake saw Ms Lee punished
with a three-month suspended jail
term by the Old Bailey last March.
The presiding judge stressed Ms Lee
bore no factual or legal responsibility
for Mrs Shelter's death, but she was
convicted under section 85.5 of the
Medicines Act nevertheless.
Just over one year on and the
Court of Appeal nullified the terms
of that conviction. The court ruled
that section 85.5, which makes it an
offence to attach the wrong label
to a medicine, should not be applied
to employed or self-employed
The judgement is a clear boost for
employees and locums who will now
avoid the threat of criminal charges
under labelling offences. The risk for
contractors though remains as the
Court of Appeal ruled pharmacy
owners are still accountable for
breaches of section 85.5.
But even though the ruling lifts
the threat of prosecution for
employees and locums under one
Judgement day: Mark Koziol and the PDA battled to overturn Ms Lee's conviction
part of the Medicines Act, it leaves a
second area untouched. Despite Ms
Lee's successful appeal, pharmacists
could face criminal prosecution for
wrong product supply under section
64.1 of the act. Ms Lee was originally
charged under both wrong product
supply (64.1) and attaching the wrong
label (85.5) offences. However, as
she pleaded guilty to the 85.5
breach, the judge chose not to
proceed with the charge under 64.1.
But once Ms Lee's conviction
under 85.5 was quashed at last
week's appeal, the prosecution
requested judges substitute for the
64.1 offence instead. The Court of
Appeal judges called for the matter
to be considered at a retrial. But, Ms
Lee has been explicit in her desire
not to return to the court again. "It
would be like returning to the scene
of a road traffic accident," one
member of her legal team told C+D.
The prosecution advised the Court
of Appeal that they would push
ahead for retrial unless it dealt with
the 64.1 offence immediately. Ms
Lee's legal team had no choice but to
concede. The judges switched the
85.5 conviction for a 64.1 offence
and issued Ms Lee a £300 fine.
This substitution deal means
dispensing errors remain open to
criminal prosecution and it has left a
sense of unfinished business around
those closest to the case. Mark
Koziol, PDA chairman and member
of Ms Lee's legal team, says: "As a
consequence of events we did not
get an opportunity to put our legal
arguments about the appropriateness
of the section 64.1 offence as we feel
that had we done so, then more
progress could have been made."
Pre-hearing, Ms Lee's legal team
had been confident of successfully
tackling the 64.1 offence. Their
chances hinged on the prompt
publication of dispensing error
guidance from the Crown
Prosecution Service (CPS) promising
pharmacists greater protection
against prosecution for errors.
Ms Lee's legal team aimed to
convince judges a retrial under 64.1
could not take place with rules over
dispensing errors about to change.
But the bid was to be scuppered
almost immediately. Within minutes
of the Court of Appeal hearing, the
CPS said it could not guarantee
guidance arriving anytime soon. In
fact discussions between the CPS,
the Department and the RPSCB had
hit "difficulties" over defining the
public interest in dispensing error
cases, judges were told.
"We were dealt a curve ball by
CPS saying this was in the long
grass," Mr Koziol told C+D outside
the court room. "That wasn't our
understanding and it meant we had
to focus on the 85.5 offence. We
could have overturned both."
Ultimately the appeal fell short
of total victory. But it would be a
harsh critic who considered it a
disappointment. Ms Lee can get on
with her life free from the burden of
a custodial sentence and
pharmacists are better protected
against prosecution for errors. The
sector must now make sure this
protection becomes full rather than
partial without losing another
aspiring pharmacist like Ms Lee
along the way.
The Elizabeth Lee Court of Appeal case
• Custodial sentence quashed and switched to a £300 fine
• Employees and locums shielded from labelling offences
■ • Fine, not jail term is now the precedent for Medicines Act breach
v« Wrong product supply offence remains
• Ms Lee unlikely to practise again
• Nq sign of dispensing error protection guidelines in near future
10 Chemist+Druggist 05.06.10
We are proud to lead the profession - the entire profession - across all sectors and for all members.
United, we have a clear; strong voice for pharmacy - one which will deliver change on the issues
that really matter to you.
Change can be dramatic, and influencing it starts with knowing the right people. Our business is to
be in the know.
Make sure your voice is heard. With your involvement, your national pharmacy boards and your
new Society are set to deliver a bright new future for your profession.
49,000 pharmacists - now that's a voice that can really make a difference.
Find out more at www.rpharms.com/membership
Royal Pharmaceutical Society
Reward locums with fair pay for their expertise
I write with concern about the
recent development in provision of
MUR services in some company/
I think the issue regarding provision
of essential, advanced and enhanced
services needs further clarification,
as some companies expect locums
to do two MURs per day on top of
providing an essential service.
It can also be a prerequisite that
locums be MUR-accredited to get
the placement. And he/she is forced
to do MURs as if they are an
essential service, and do not get any
extra remuneration for doing MURs.
It is important this unfairness is
addressed, because locums have
invested time and money to attain
MUR accreditation, primarily for
their own professional and financial
betterment and not for companies
to exploit this. This applies particularly
Talk to C+D on Twitter. Sign
up at twitter.com and follow
^ Email us your letters,
/^p including your name,
address and contact
"THE PROVISION OF ADVANCED AND
ENHANCED SERVICES BY A LOCUM SHOULD
BE TREATED AS A SEPARATE AGREEMENT"
to MURs but is equally relevant to
other enhanced services that locums
have invested in getting accreditation.
The provision of advanced and
enhanced services by a locum
should be treated as a separate
agreement from essential services in
much the same way the contractor is
paid extra for such services.
Additionally, it is difficult and
more stressful to provide a safe and
efficient pharmaceutical service
when the only 'responsible'
pharmacist is struggling between
providing an essential service and
being in consultation with a patient
on advanced or enhanced services.
A mutually beneficial option has to
be developed with a patient focus.
Alternatively, companies could
use an MUR-accredited employee or
locum to meet targets for maximum
financial reward without subjecting
locums or employees to rather
unsafe juggling of responsibilities.
Perhaps pharmacist area
managers or other desk-based
company pharmacists could make a
more constructive contribution by
going into branches to conduct
MURs rather than frontline
pharmacists being asked to do more
Name and address supplied
Highlights from C+D on Twitter
From nights out to the Time Warp, join the debate at • 1 1
www.twitter.com/chemistdruggist ^ j
@CaryParagpuri: Just spoken to our compere for the C+D Awards - you re in <J5l
for a fantastic evening is all I can say. »
@CandDHannah: Looking forward to staying in the place where The Rocky \, r ;<
Horror Show was filmed [for the CAMRx convention]. In fact, weren't they < Os_.
supposed to be at a convention?!
@CandDChris: @CandDHannah yeah, an annual Transylvanian convention. If
you don't get a Time Warp in, I shall be disappointed.
@CandDHannah: Nice has claimed minimum pricing on alcohol will reduce
excessive drinking by 10%. Based on what? Irish law in 1987 didn't work.
12 Chemist+Druggisl 05.06.10
Check out what's on TV this week
Anti-mosquito spray Incognito in
new formula relaunch
Anti-mosquito range Incognito will
relaunch its spray in a new formula
from this month.
The new formulation has been
tested by the London School of
Hygiene & Tropical Medicine
(LSHTM) as giving 100 per cent
protection against Anopheles
gambiae (African) mosquitoes, and
has been approved by the Trading
Standards Institute as "clinically
proven to protect against malaria",
according to the company.
Incognito spray will continue to
contain Javanese citronella, but in a
lower concentration than the
It will now also contain
Eucalyptus maculata citriodora,
which has also been tested by the
The research was reported in the
British Medical Journal.
Tel: 0207 221 0667
• The insect repellent market
is worth £6.9 million.
• Pharmacy accounted for 28
per cent of the market sales.
• The top selling insect
repellent brands are Jungle
Formula, own brand and Autan.
Source: 1RI value sales, 52 weeks to
February 20, 2010
Price drop for Omnitrope
Slimshot price cut
DTP has announced a summer
price reduction for Slimshot from
£16.99 to £9.99. Slimshot is a
weight loss drink made up from
effervescent tablets. The product
is available in Tesco, Superdrug
and some independent
pharmacies, according to DTP.
Tel: 0115 924 8160
Sandoz has announced a price drop
for Omnitrope (liquid somatropin for
injection) from June 1.
The recombinant growth
hormone is now the cheapest in the
NHS price list, Sandoz says.
Nice published guidelines last
month on the relative cost and
effectiveness of somatropin
products to treat child growth
deficiences. The guidance now
includes Omnitrope as one of seven
recommended somatropin products
- the first time that Nice has
recommended the use of a
biosimilar product, says Sandoz.
The price for Omnitrope 5mg will
reduce from £91.33 to £86.74; for
5mg/1.5ml the price will drop from
£456.65 to £433.82 and for 10mg/
1.5ml from £913.20 to £867.64.
Price: £433.82 (5mg/1.5ml);
Pip codes: 325-7722; 335-3067
Tel: 01420 478301
Simple has relaunched its Simple
Baby range, which is available in
Boots, Sainsbury's, Morrisons and
Superdrug. The range comprises
moisturising wipes, all-in-one
wash, moisturising bath wash,
moisturising shampoo and talc.
Tel: 0121 712 6523
Oxford Nutrascience is set to launch
two supplement products using its
confectionery system that it says
uses soluble fibres to allow functional
ingredients such as vitamins to be
added without compromising taste,
texture and stability.
One chew is a cranberry
supplement and the other is a
children's chew that contains pre-
simple Baby relaunch New supplements to chew over
biotic fibre, omega-3 and vitamins A,
C, D and E. They are set to launch in
the second half of the year.
The launch announcement follows
an "exclusive" agreement last
month with European confectionery
manufacturer Lamy Lutti.
Do national awareness
associated retail sales?
"I have to say
they don't really
affect sales, but
they do help with
have had a lot of
uptake onto those schemes and this
improves our professional image as a
good source of help and advice."
Linda Bracewell, Baxenden
"Some of them
are quite good -
in particular No
Smoking Day and
is about blood
pressure. However, National Obesity
Day didn't have much of an effect."
David Badham, Stewart
Pharmacy, Evesham, Worcs
Off the shelf view: Three quarters
believe awareness campaigns boost
pharmacy sales, but the remainder
have doubts about their impact
Some suggest campaigns have a
bigger effect on uptake of services.
Next week's question:
Did a mostly unseasonably warm
May boost your sales? Vote at
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are connected to a better future. So, with the demands being made on you by the current National Programmes, get better
connected today. Call your ProScript LINK Account Manager, email firstname.lastname@example.org or visit www.aah.co.uk.
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Test yourself with the C+D news quiz. Go to
Time for sector to make a stand
With the NHS financial landscape looking decidedly bleak, Alliance Healthcare chairman
i in b m ii i ves only u united pharmacy front will see the sector survive
At last the protracted general
election activity is at an end and we
have a coalition government. Its task
will not be an easy one as recession
will lead to spending cuts, high
unemployment and increasing
pressures on the NHS. I wish David
Cameron and Nick Clegg well, but
the more I think about this, the more
I see parallels with community
Our profession will not be
immune from these changes and I
fear that the removal of £20 billion
from the NHS budget between 2011
and 2014 will change the face of
community pharmacy as we know it.
The profession needs to face up
to the fact that in these times of
austerity we're not going to be
immune from it.
The days of making relatively easy
money are disappearing and if we're
going to survive, as I believe we will,
we're going to need strong and
But the recent changes at the top
of the sector's professional and
political organisations suggest to me
that that there may be a power
We need somebody to cut
through all the rubbish and get hold
of this profession to take it forwards,
but I don't see anybody on the
horizon to do it. And this worries
me at a time of unprecedented
change that will see us needing
management by a proactive, strong
and unified leadership.
The changes at the RPSCB in
Lambeth will mean it could take the
professional leadership body some
time to develop and it may be 12
months before we really know how
things are going to pan out there.
And the devolution of the global
sum to PCTs may marginalise PSNC
to some extent. I am a great admirer
of Sue Sharpe and her team but I just
cannot see how they can possibly
manage 150 different PCTs
effectively - even more so given the
variable quality of our LPCs.
The NPA now needs to appoint a
new chief executive, though, and this
could be the person that is vital to
the future development of
community pharmacy. I urge the
association's appointment board to
think long and hard about this for I
■'■'■■';•: l! ' '■■> i in he
suggest to me a
MIKE SMITH, ALLIANCE
believe that the NPA can become
the organisation that brings all of
the bodies representing the sector
together - splinter groups and all.
The NPA chief executive needs
to be a business leader and a
troubleshooter and the role of the
association should be that of
leadership. In my 42 years in
pharmacy I have seen movement to
unity but the old turf wars have
always prevailed and nothing has
happened. But now things are very
different, and this is why I see the
parallel with politics. The old
loyalties and adversarial politics
must become a thing of the past.
The NHS cake will shrink and
strong leadership must ensure that
we are sitting at the table and not
underneath picking up the scraps left
by others. We've just pootled along
for years with all the divisions in the
sector but we need to become
leaner and meaner and demonstrate
a really strong united front to the
Department of Health.
The fact that pharmacy has saved
the NHS £1.8bn in five years must
put us in a strong position for further
investment - but this will be hard
won. The pharmacy bodies should
be thinking about getting together.
The Conservative-Lib Dem
coalition is committed to the
reduction of bureaucracy. We must
ensure that existing relationships
are strengthened and new ones
established as quickly as possible -
cost-saving and not pharmacy will
be at the top of the agenda. We've
got to go for it or I can see us being
We have a great future in
community pharmacy - five million
visits a day and we are highly
respected professionals. But we
will have to fight for it.
Your action plan
from Mike Smith
MPs: Remind them about the
APPC vision for pharmacy left
behind by former chairman
committees: The global sum has
been devolved and I can see
some of the money just
disappearing when the savage
cuts hit the NHS. Talk to LPCs
about Pharmaceutical Needs
Assessments because we have to
ensure those are prepared in a
way that is factually correct or it
could affect our livelihood.
Primary care trusts: Talk to your
LPC but if you're not seeing
action, go directly to your PCT -
it's about kicking the door down.
Your NPA representative: If you
share my concerns I suggest that
you contact your NPA regional
director now - they are there to
represent you, and my
experience of the NPA Board
many years ago suggests that
they will listen. Enough pressure
will mean that the executive
must also take action.
Tell us what you think: haveyour
What the pharmacy bodies say
"PSNC acts as a strong, unified
voice for pharmacy on NHS
matters. We are proud of the
tremendous progress pharmacy
has made in recent years in
developing its national influence
and building a robust negotiating
"It does not follow that the
devolution of global f unding to
PCT level will lead to the
destruction of the national
framework. We will continue
to work at a national and local
level to ensure this transition
is managed effectively, and
that pharmacy's capacity to
deliver high quality NHS services
is not impaired."
Sue Sharpe, PSNC chief
"The Society is the key leadership
body representing the whole of
pharmacy. We are working
increasingly closely with the
other pharmacy bodies, and
already we are promoting the
pharmacy agenda with
governments from all three
Jeremy Holmes, RPSGB chief
executive and registrar
"The sector does need a strong
voice. At the NPA we have
brought somebody in specifically
to do that job, but the NPA
belongs to its members and
the profession needs to get
Ian Facer, NPA chairman
14 Chemist+Druggist 05.06.10
Check out our guide to getting good professional advice
The Finance Zone
PART 5: Retirement planning. The earlier you
start the better, says accountant Richard Baker
Retirement planning is something
most of us commit little thought or
time to. Early in our working lives we
have other priorities, such as getting
on the property ladder or paying off
student loans and, later on, sending
our children to university or buying a
The purpose of this article is not
to convince you to make pension
contributions or to tell you what to
invest in. A good independent
financial adviser will help you to do
this. But you should consider how
you are going to fund your
retirement, and the earlier you start
Of course, your personal
circumstances will change over time
and the plan will need to be
revisited. Contributing monthly to a
personal pension plan is one way of
funding your retirement, but there
are many other ways
For personal pensions, basic rate
taxpayers generally make
contributions net of tax and the
pension provider claims the income
tax back. For example, if you
contributed £80, the provider would
claim back the income tax of £20,
making your total contribution £100.
Higher rate taxpayers are
generally entitled to tax relief at 40
Richard Baker: take advantage of tax
relief to boost pension contributions
per cent. Using the previous
example, the pension provider would
claim back £20 (20 per cent) and the
taxpayer would claim back the other
£20 (20 per cent) via their tax
return. Whether the full 40 per cent
is available will depend on how
much your earnings are.
There have been some changes
recently that are worth mentioning.
For those individuals lucky enough
to have a relevant taxable income of
£130,000 or more, there are now
restrictions on higher rate tax relief
• Plan how you are going to
fund your retirement as early
• Revisit this plan as your
• Pension contributions are
entitled to variable tax relief
depending on your taxpayer
• There are new restrictions
on higher rate tax relief on
pensions contributions for
those with a relevant taxable
income of £130,000 or more.
on pension contributions. This was
brought in to prevent such
individuals from obtaining tax relief
at 50 per cent on their pension
contributions. The rules surrounding
this are very complex and it is vitally
important you seek advice.
Richard Baker is a partner at
accountancy firm Horwath Clark
Horwath Clark Whitehill
Extracting profit from your
The C+D Finance Zone Supported by
Call 0800 328 7270 to talk to a NatWest
advisor (quoting 'C+D') or to make an £^ NStWfiSt
appointment with a NatWest pharmacy
specialist relationship manager Hel P ful Bonking
Time to talk about dry n
Approximately 20% of people suffer symptoms of dry mouth', primarily related to disease and
medication use. More than 400 medicines are associated with dry mouth 2 , especially if three
or more are used together 3 .
The Biotene System
The Biotene formulations supplement natural saliva, providing some of the missing salivary enzymes and proteins in patients with xerostomia and hyposalivation
to replenish dry mouths.
The Biotene system allows patients to choose appropriate products
to fit in with their lifestyles:
Products specially formulated for dry mouth:
• Biotene Oralbalance Saliva Replacement Gel
- For relief of dry mouth
• Biotene Oralbalance Moisturising Liquid
• Biotene Fluoride Toothpaste
• Biotene Moisturising Mouthwash
The range is specially formulated for individuals experiencing dry mouth
or related oral irritations
• Alcohol free • Sodium Lauryl Sulfate (SLS) free • Mild flavour
The Biotene range:
• Helps maintain the oral environment and provide protection
against dry mouth
• Helps supplement saliva's natural defences
for dry mouth
1. Billings RJ Sludies on the prevalence of xerostomia Preliminary results Canes Res 23 Abstract 124. 35lh0RCA Congress
1989 2. Eveson JW 'Xerostomia' Periodontology 2000 48 85-91 3. Sreebny IM. Schwartz SS 'A reference guide to drugs
and dry mouth - 2nd edition' Gerodonlology 1997 14 1, 33-47
BIOTENE is a registered trade mark of the
GlaxoSmithKline group of companies
05.06.10 Chemist+Druggist 15
What do you think?
Locum or employee, the stresses remain
"AN AREA MANAGER
A 'CORPSE WITH A
I was reading something recently about the high
proportion of locum pharmacists working in
community pharmacy, and that this was not
necessarily a good thing. This short article in some
journal - I forget which - seems to have raised the
hackles of a number of locum pharmacists,
including Richard who locums for me.
While I understand some points the authors
were trying to make, I think they should have
approached it from another angle, asking why it
is that so many in the profession choose this
form of employment.
It doesn't take much reading of C+D to get a
feel for why pharmacists may be reluctant to
become an employee. I can remember my many
years working for a multiple, and at one point I
was so much a company man that if you cut my
head off I had the company name running down
my middle like a stick of rock.
What made me change and work as a locum for
a couple of years? I began to realise that the cliche
"Our most valuable asset is our staff" had been
replaced with "Our most valuable asset is money,"
and staff came in at number nine - behind
paperclips. So reading headlines such as
"Employees not given support for stress" and
"Pharmacists fear for job security" makes me
wonder not why there are so many locums, but
why there aren't more!
Now Mrs Xrayser - being a registered pharm
tech - has met more pharmacists than I, and is not
backward in coming forward when it comes to
expressing her opinion. She has worked with
pharmacists with mental problems, others who
wander off to do their shopping while scripts are
waiting, others who are abusive, or lazy, or late, or
worse, and these are both locums and employees
- so there's nothing special about being an
employee. And yet some people still hold a very
negative attitude, perhaps best demonstrated by
an area manager's description to me of locum
pharmacists as a "corpse with a certificate".
Richard says that being a locum gives him a
chance to constrain the stress that he works
under, and the C+D survey results that said 85 per
cent of employees who reported stress and
workplace issues received no support, along with
the huge growth in membership for the PDA,
certainly back up my experience of employment.
Prospective employers should learn the lesson
of Maslow's hierarchy of needs, which says that
once we have the basic requirements of food,
shelter and companionship, we need to feel good
about ourselves. This means that a well paid
profession - such as pharmacy - can't be engaged
by money alone.
In light of the 16 months since the old Society
promised action on stress, this is a lesson that the
PLB ignores at its peril, because it doesn't matter
how many colourful benefits I get for £4 a week if
it doesn't make a difference to my day job, be I
employee or locum.
The threat of hangs heavy over us
We all make mistakes. Most
community pharmacists, certainly
those who have practised five years
or more, tell a lie when they claim
they've never made a dispensing
error. Only a pharmacist knows
that gut-wrenching feeling as it
becomes clear a mistake has been
made and a patient has taken the
Accidents happen even to the best
and where we cannot undo what is
done, we can - as well as the
apology and the compensation -
learn from our mistakes so that it is
not repeated. This makes good
business sense and is core to total
Since April 1, 2009, it has been a
requirement that community
pharmacists, in common with CPs
and dentists, report any serious
adverse incidents (SAI) to the health
and social care board (HSCB).
Whereas the scope of what
constitutes an SAI is wide ranging
and includes loss of patient data, for
example, by far the most likely SAI
to occur in a community pharmacy
is a dispensing error.
For some years now I have used
an error reporting system where all
staff record, anonymously if they
wish, any incident that occurs from
near misses to very serious events
such as where a patient got the
wrong medicine, took it and suffered
Once staff got comfortable
reporting in the error log, the system
became an invaluable tool for
improving our overall quality. Each
reported incident is assessed and
from this we might do nothing, we
might introduce new ways of
working or we might get some
So, in theory, I am a strong
supporter of the requirement for
pharmacies to report SAIs to the
HSCB. Good intelligence of what is
going wrong in a pharmacy
elsewhere allows me to take steps to
stop it recurring in my pharmacies.
But this scheme faces a major
barrier: a dispensing error remains a
criminal offence and once reported
to the HSCB it will end up with the
DHSSPS. There seems little latitude
there in dealing with such
revelations, therefore it is likely that,
since a criminal offence has been
committed, a case file will be passed
to the Public Prosecution Service.
It will be up to them to decide if:
one, it can secure a conviction in
the courts and two, a conviction is
in the public interest. On point one
the defendant, by his reporting, has
just pleaded guilty to an offence.
Whether a conviction is in the public
interest then becomes the main test.
I am unhappy that pharmacists will
be exposed in this way and I am sure
that some may avoid reporting SAIs
which, if uncovered at a later date,
will attract an even heavier penalty.
We need to be treated in the same
ways as doctors and dentists.
Terry Maguire is a community
pharmacist in Northern Ireland
"A DISPENSING ERROR
REMAINS A CRIMINAL
OFFENCE AND ONCE
REPORTED TO THE
HEALTH BOARD, IT
ENDS UP WITH THE
16 < he 05.06.10
17 Blood tests: pt 1 ^ 19 Arthritis meds P 20 Eye and earcare r 24 New Nice rules ^ 26 Time planning
Your weekly CPD revision guide
Interpreting blood test results (pt 1 )
How to use blood test results to support disease management
Russell Greene MRPharmS
The main reason for doing investigations is to aid
diagnosis. Sometimes this can be definitive, such
as a high blood glucose or thyroxine, or merely
supportive, as with blood gases. Other important
rationales for investigations are monitoring
disease (eg creatinine in renal impairment),
screening (eg cholesterol) and drug monitoring
(eg adverse effects or therapeutic levels).
Giving patients their results
Patients may ask for guidance on both the
purpose and the interpretation of tests ordered by
other health professionals. The pharmacist should
be cautious, however, because of the variety of
different indications and the detailed interpretation.
Unless you have full access to the patient's
medical history, comments should be couched in
general terms, with the recommendation to
discuss the results with the healthcare worker who
ordered the test.
In most cases the report will cite the level found
and the expected ('reference') range. This is the
range found by that laboratory, using their
particular method, in the majority (more than 95
per cent) of the population they normally sample,
and which is assumed to represent the limits in
It must always be remembered that any
biological measurement varies within a
population (eg blood pressure is rarely exactly
120/80 in every healthy individual); for this
reason the expression 'normal values' is usually
avoided. Moreover, for any individual,
measurements vary at different times - blood
pressure varies with exertion, blood glucose
following meals, and Cortisol with time of day. This
is why test conditions must be controlled and/or
reported, and also the reason fasting is specified
for many blood tests.
Results near but outside these limits must be
regarded with care, as the patient could be a
perfectly healthy 'outlier'. A repeat test might be in
order, or other evidence of illness sought. Further,
the importance of the extent of permissible
variation varies greatly for different tests. Quite
small rises in potassium level, for example, could
be acutely dangerous to the heart; conversely,
creatinine levels may be twice normal without
immediate ill effect (and may be greater than five
times normal in a renal patient).
Finally, using a battery of screening tests
increases the likelihood that one result will by
chance be outside the reference range but not
represent any real problem.
Blood presents the most easily accessible and
most informative window on the internal
condition of the body. Many natural processes are
controlled or supplied by blood-borne substances
(eg nutrients, gases, mediators), and the products
or agents of pathological processes are usually
blood-borne. Hence blood tests are the most
common and often the most useful initial
The terms 'serum level' and 'plasma level' refer
to which particular fraction of the blood is tested
or reported, but for our purposes are usually
interchangeable with blood level.
These two articles will approach testing by
discussing the tests most frequently used in
common diseases, and what results outside the
reference range might signify. A list of tests suitable
for various diseases is in Table 1 on p18, and a table
of reference ranges for these tests will be online
next week in the full version of part 2 in this series
What follows is necessarily an overview; for
more detail, see the list of further reading available
online at www.chemistanddruggist.co.uk/update.
Anaemia is common and it is frequently but
incorrectly assumed to mean a low red blood cell
(RBC) count. However, the definition of anaemia
rests solely on a low haemoglobin level: the lower
limit is about 1 1g/dl (female) or 12g/dl (male).
Mild anaemia would be 1 to 2g below this, and
very serious anaemia less than 6g/dl. If RBCs are
each deficient in haemoglobin (mean corpuscular
haemoglobin - MCH), the RBC count itself may be
near normal even though haemoglobin is reduced,
so this is still anaemia. Conversely, extra large
RBCs (macrocytes) in pernicious anaemia may
initially compensate for a reduced corpuscular
number or mean corpuscular haemoglobin
Anaemia is frequently but by no means always
due to iron deficiency. The cause of the anaemia,
knowledge of which is essential for rational
treatment, is obtained only by measuring the size,
shape, number and haemoglobin content of RBCs.
Other important information is obtained by
measuring folate, B 12 , and parameters of iron such
as transferrin and ferritin.
In some forms of anaemia, especially when due
to acute blood loss, the proportion of immature
RBCs (reticulocytes, normally about 1 per cent) in
the blood rises as RBC production in the bone
marrow increases to replace the losses. Although
« <*J B MB CLINICAL
■T 18 Blood tests: pt 1 ^ 19 Arthritis meds ^ 20 Eye and earcare ^ 24 New Nice rules ^ 26 Time planning
Table 1 Disease state and
relevant blood tests
folate; B 12
Red blood cell (number,
Hb content, size);
White blood cell (number),
White blood cell (subtype,
CD4 white cells
Creatinine level; creatinine
Na, K, Mg, chloride,
o 2l co 2
Enzymes: AST, ALT, ALP,
Creatine kinase, AST,
(LDH), troponin (Ml); brain
natriuretic peptide (heart
hormone (TSH), free
ALP, calcium, phosphate,
Urate (uric acid)
Abbreviations ALP - alkaline phosphatase; ALT -
alanine aminotransferase; AST - aspartate amino-
transferase; GGT- gamma-glutamyl transferase
this will not occur in anaemias due to chronic
deficiencies, eg of iron or folate, a rise in
reticulocyte count can be used as an index of the
patient's response to iron therapy.
White cells (WBC) are a diverse group, but
generally their function is to respond to external
attack by initiating inflammation and/or an
immune response. Therefore any general rise in
WBC count (leucocytosis) implies infection or an
inflammatory state. A raised neutrophil number is
a sensitive indication of the latter, while
lymphocyte numbers generally rise in response to
microbial infection. In leukaemia, the WBC count
may be greatly elevated but the cells are effete.
Allergy increases particularly the eosinophil
count. Conversely, damage to the bone marrow
(eg cytotoxic and some immunosuppressant
drugs) is indicated by a fall in total WBC count
Bone marrow depression and certain drugs (eg
carbamazepine, ACE inhibitors) can also reduce the
platelet count (thrombocytopenia) causing
bruising and bleeding. Note, however, that aspirin
and other antiplatelet agents do not reduce
platelet count. A platelet excess (thrombocytosis)
is far rarer.
During inflammation, concentrations of
inflammatory mediators in the blood increase,
especially macromolecules like antibodies and
acute phase proteins. These tend to bind to and
cross-link red cells, causing them to clump, and in a
stationary specimen of (anticoagulated) blood this
increases the rate at which red cells sediment. This
is the erythrocyte sedimentation rate (ESR),
measured in mm/hour as anticoagulated blood
settles in a test tube and a depth of clear
supernatant fluid appears. It is a useful although
only approximate measure of the degree of
inflammation. For example, ESR will be raised
during a rheumatoid arthritis flare-up, but it will
fall back to normal once the attack subsides or
Urea and electrolytes
Usually known by the abbreviation U&Es, this is
the traditional term used broadly for tests of renal
function and fluid and electrolyte balance,
although other abnormalities are also covered.
Blood urea itself is not a helpful measure of renal
function because many other factors can affect it.
However, it is a useful index of hydration as low
levels indicate haemodilution or overhydration,
while high levels indicate dehydration. Sodium
levels can also indicate the level of hydration,
but because many factors affect sodium,
interpretation must consider other tests and
Creatinine level is the best general index of renal
function as it is directly correlated with renal
filtration, and allows the glomerular filtration rate
(GFR) to be calculated. This is one measure that
can reach high levels without apparent acute
effect, because renal function can deteriorate
markedly before symptoms appear. Thus, although
the usual creatinine level is about 100mmol/L, it
can rise to between 500 to 1,000mmol/L in severe
The commonest causes of potassium imbalance
are dietary and drug-induced. Because muscle
function, especially the heart, is critically dependent
on the plasma potassium level staying within the
narrow limits of 3.5 to 5mmol/L, the body strives
to maintain this. A low level (hypokalaemia) is
commonly caused by dietary insufficiency
(especially inadequate fresh fruit and vegetables)
or by thiazide or loop diuretics. Among other
problems, hypokalaemia reduces the threshold for
digoxin toxicity. High levels (hyperkalaemia) can
be induced by unmonitored potassium-sparing
diuretic therapy or ACE inhibitors/angiotensin II
receptor antagonists, and especially combinations
of these. Potassium supplements are now rarely
used, but were a problem in the past, and even
excessive use of potassium citrate mixture has
been recorded as a cause of hyperkalaemia, which
can cause life-threatening arrhythmias.
Acid-base imbalance can have many causes.
It is indicated by blood pH, but the possible cause
is narrowed down by also considering the
bicarbonate and chloride levels. Acid-base
imbalance is linked with potassium imbalance, eg
acidosis can cause hyperkalaemia and vice versa,
so the two measurements should always be
One of the main purposes of the cardiorespiratory
system is to maintain oxygen delivery to the
tissues and remove carbon dioxide. Reduced
arterial oxygen partial pressure suggests either
that the heart is not pumping blood adequately to
the lungs or that the lungs are not oxygenating
properly. At the same time carbon dioxide levels
would rise, and this would lower pH (acidosis).
Although acidosis can have other causes, this is
the simplest form and one of the most common.
Known as respiratory acidosis, it occurs when lungs
are not clearing carbon dioxide adequately and,
again, this may be pulmonary or cardiac in origin.
Obviously other tests would be needed to
resolve these matters. For example, heart failure
patients would display cyanosis owing to high C0 2
levels, but so would COPD patients. However, in
the former there would probably be peripheral or
pulmonary oedema, and in the latter poor lung
function tests (eg FEV^.
Dr Russell Greene MRPharmS, is a
pharmaceutical writer and consultant
Further reading is available in the full version of
this article online at www.chemistanddruggist.
co.uk/update and in the CPD on p19.
Download a CPD log sheet that helps you
complete your CPD entry when you
successfully complete the 5 Minute Test for
this Update article online (p19).
Part two describes the blood
investigations used to diagnose
and monitor specific diseases
18 Chemist Druggist 05.06.10
I Sign up for clinical newsletters at
Interpreting blood test results
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at www.chemistanddruggist.co.uk/update or by calling 0207 921 8425.
Signing up also ensures that C+D's weekly Update article is delivered
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Get a CPD log sheet for your portfolio when you successfully complete
the 5 Minute Test online.
Besides haemoglobin, what other blood parameters
should be measured when testing for anaemia? What
does a raised eosinophil count indicate? Why are
creatinine levels measured? What are the causes of
This article discusses the blood tests most frequently
carried out in common diseases and the interpretation of
the results. It includes information about tests involving
blood cells (anaemia and bone marrow depression), urea
and electrolytes, and blood gases.
• Find out more about the different types of anaemia
and the blood tests used for diagnosis on the Lab Tests
Online website at http://tinyurl.com/35pojw4.
Update your knowledge of the full blood count
test on the Lab Tests Online website at
Find out more about blood tests in kidney disease by
reading information on the Edinburgh Renal Unit website
Read more about blood tests for potassium and
calcium on the Lab Tests Online website at
Are you now familiar with the tests involving blood cells,
urea and electrolytes, blood gases and the conditions
they help diagnose? Could you advise patients about the
MttHilllMflHI interpretation and limitations of the results?
Complementary medicines for arthritis
David Spencer, pharmacist at the
Jpdate Pharmacy, is visiting his
Blderly uncle Morris.
During their conversation Morris
>ays: "David, you're a chemist so you
mow about these things. What do
/ou think about this glucosamine
and chondroitin for arthritis? I keep
seeing it advertised in the newspaper
and wonder whether it's worth a try.
And, if it's any good, could I get a
prescription for it from my doctor?"
"Are you taking anything for your
arthritis at the moment?" David
"Yes, I've got some tablets from
the doctor. Let me show them to
you," and Morris takes a pack of
naproxen 250mg tablets out of a
drawer. "They help, but it's not
going away. I just wonder if this
glucosamine, instead or together
with them, might be more effective."
David replies: "Uncle, what you've
got is called osteoarthritis and I'm
afraid there's no cure for that. Your
naproxen will just help ease the pain
and stiffness. To help me advise you,
can you tell me if you take any other
"Oh, quite a few," says Morris and
takes out of the drawer packs of:
indapamide 2.5mg, labelled one in
the morning; isosorbide mononitrate
m/r 60mg, 1 om; metformin 500mg,
1 tds; warfarin 3mg, 1 om.
David examines them and says:
"Well, here's my advice about
glucosamine and chondroitin."
1. Are glucosamine and
chondroitin safe for Morris to
2. Are there any general cautions
or contraindications for
glucosamine or chondroitin?
3. Are they effective in treating OA?
4. Is exercise beneficial for OA?
1. Both glucosamine and chondroitin
appear to be well tolerated
generally. However, animal studies
have raised the possibility that
glucosamine may worsen insulin
resistance, although so far studies in
humans have not substantiated the
risk. Nevertheless, Morris should
monitor his blood sugar level
particularly carefully if using
glucosamine. Also glucosamine and
chondroitin both enhance the
anticoagulant effect of warfarin and
concomitant use should be avoided,
so Morris should not take them.
2. Glucosamine is manufactured by
processing the crushed shells of
crustaceans and may lead to an
allergic reaction in individuals
allergic to seafood.
3. As more clinical trial results have
become available, the initially fairly
optimistic opinion of the efficacy of
glucosamine and chondroitin, from
mostly small and producer-
sponsored studies, has been
reversed. A recent large-scale
randomised controlled trial involving
patients with OA of the knee
revealed that glucosamine,
chondroitin, or both, did not differ
from placebo for pain relief. 1
Another found glucosamine no
better than placebo in reducing
symptoms and progression of hip
OA, while a meta-analysis
concluded that the symptomatic
benefit of chondroitin for this
condition was minimal or non-
existent. 23 Nice has suggested
that glucosamine products should
not be recommended for the
treatment of OA.
4. There is evidence that aerobic
walking and muscle resistance
training are beneficial for knee and
hip OA. Manipulation and stretching
are also helpful for hip OA.
References are available online at
Do you have an idea for a Practical
Approach scenario or would you
like to write one? Email us at:
05.06.10 Chemist : Druggist 19
17 Blood tests: pt 1 ^ 19 Arthritis meds 20 Eye and earcare 24 New Nice rules 26 Time planning
CA'ft* >>■ Mf FOCUS
Eye and earcare
Pharmacists can capitalise on the £64 million eye and earcare market by focusing on
education and making the most of seasonal opportunities, reports Hannah Flynn
Eye and earcare category sales together
are worth £64 million, according to
data from IRI and IMS, and the eyecare
market in particular is worth over £56m and
showing double digit growth of nearly 14 per
cent. Strong television campaigns for products
including Optrex Actimist and Murine eye drops
have driven the healthy growth in the eyecare
sector, say the manufacturers.
But grocery's eyecare market share is growing
significantly faster than pharmacy's, so how can
pharmacists ensure their customers are getting
the best out of eye and earcare products and
make sure they capitalise on the growth at the
An increase in the number of patients seeking
advice from their pharmacists is a positive trend,
particularly in eyecare, says Philip Lewis-Williams,
managing director of preservative-free
ophthalmics manufacturer Spectrum Thea.
Mr Lewis-Williams says: "We are seeing a trend
towards patients asking for advice before going to
their GPs. The trend will continue for self-
medication. I think pharmacies have an
important part to play there and I think by
providing more education they can increase sales
in this area. [For example], pharmacists could
give advice for blepharitis, which is the biggest
cause of cancellation of cataract operations in
Three tips for boosting
eye and earcare sales
1. "To help maximise sales and ensure the eye
drops are used to best effect, help customers
narrow down the decision process and select
the relevant product by using signage, shelf
talkers or direct assistance."
Sally Walton, marketing manger, Murine
2. "Make sure patients know there is a 28-day
expiry date on their eye drops, then they will
come back and get more."
Alison Lyons, divisional services manager,
3. "You need to let your customers know
where to find products, so signpost them with
Adam Bishop, UK pharmacy channel team
20 -.i 05.06.10
Get Category Focus articles emailed to you
Some educational tools for pharmacists
have launched recently, including Moorfields
Pharmaceuticals' website for the diagnosis
and treatment of dry eye syndrome
(www dryeyesmedical.com), and marketing
manager for eye drops manufacturer Murine Sally
Walton agrees educating customers is key to
Ms Walton says. "Educating the customer
about the environmental causes of dry eyes, such
as central heating, air conditioning, computer use
and travel, can help identify the cause of the
common problem and identify when it is best to
administer eye drops."
In terms of brand vs generics, Optrex is the
most popular eyecare brand, according to IRI, but
in earcare, Alison Lyons, divisional services
manager for the Co-operative Pharmacy, says
generic olive oil and sodium bicarbonate eardrops
are among the most frequently requested
products by customers.
Ms Lyons says: "There are some people referred
to us by the nurse or CP who need to clear their
earwax. They usually request those rather than
Timing and placing of both eye and earcare
products can be crucial to sales, as well. Ms
Lyons says that placing eye drops with hayfever
remedies during the hayfever season could
boost sales, as could suggesting them
Eye and earcare
Eyecare range Golden Eye launched
a website in April this year,
information for consumers on the
range of drops and ointments, how
to prevent eye infections, and FAQs.
And there is also a section dedicated
to trade, where training materials
are available for downloading.
Manufacturer Dendron says the
Golden Eye brand has a long clinical heritage, and that its popularity can be seen through its sales. It
is the third best-selling eyecare range in the UK, IRI data shows.
The range includes Golden Eye Standard Ointment and Drops for minor eye infections and
irritations including conjunctivitis, blepharitis and styes. It also includes Golden Eye Antibiotic Eye
ointment and drops, for acute bacterial conjunctivitis.
UK Hsl eves
wel & i lean
contai t lorn
Ceuta Healthcare has announced the
largest ever UK press campaign for the
Murine range of eye drops, to be run
The campaign has been designed to build
the brand profile, but most significantly to
educate people about the role of eye drops,
according to the company.
Figures are not yet available for the
campaign, which will continue until the end
of the year, but it will include the brand working with a celebrity case study and an "extensive"
consumer print campaign, Ceuta says.
The products in the range include Murine Bright & Moist Eyes, Murine Dry & Tired Eyes and
Murine Wet & Clean. All three have an RRP of £3.99/15ml.
dry & tired
The eye and earcare sectors are collectively
worth £64 million.
The eyecare sector has grown significantly
over the past year, with an almost 14 per
cent rise year on year (IRI value sales, 52
weeks to March 20, 2010). Pharmacy,
including Boots and Superdrug, holds almost
three quarters of the £56. 4m market;
however, its grocery rivals are seeing faster
growth of 22 per cent, compared to 11 per
cent. IRI says the market's double digit
growth was significantly driven by last year's
launch of Optrex Actimist.
The total earcare market is smaller,
worth £7.6m (IMS, MAT December 2009),
with 2.2 million units sold annually. It is
predominantly made up of eardrops (84 per
cent), worth £6.4m.
Olive oil-containing products are showing
strong growth of 57 per cent year on year.
Market changes 2009-10
Total market value
2. Own label
3. Golden Eye
Source: IRI value sales, 52 weeks
to March 20, 2010
m SfwiWirouj* Snuff i
o Prevention and relief from itchy allergy eyes
o Used at the first sign of hayfever eye symptoms,
Optrex Allergy Eyes eye drops can help prevent
symptoms from getting worse
° AND once symptoms have started Optrex Allergy
Eyes eye drops provide fast, direct relief
Optrex Allergy Eyes eye Drops: Eye drop containing
Sodium Cromoglicale 2.0%w/v.
Indications: For the relief and treatment of seasonal
Dosage: One or two drops in each eye four times a
day or as indicated by the doctor.
Contraindications: Hypersensitivity to sodium
cromoglicate, benzolkonium chloride or disodium
Precautions: Discard ony remaining contents four
weeks after opening the bottle. As with other
ophthalmic solutions containing benzolkonium chloride,
soft contact lenses should not be worn during the
Undesirable effects. Transient stinging and burning
may occur after instillalion, other symptoms of local
irritation have been reported rarely.
Legal Classification: P
Licence Holder: Tubilux Pharma SpA, Pomezio, Italy
Licence No: PL 17918/0005
CLINICAL CLINICAL BUSINESS CLINICAL CAREERS
4 17 Blood tests: pt 1 ^ 19 Arthritis meds 22 Eye and earcare p 24 New Nice rules P 26 Time planning
to customers at the point of sale.
The sales of earcare products fluctuate slightly
throughout the year, according to IMS data, with
a slight dip in sales seen during the winter months
of January to February and November to
The increasing age of the population could also
be accountable for the rise seen in the earcare
sector. Director of the Nash Croup Amin Bandali
said his pharmacy surveyed its local community
to find out what services they wanted.
He said: "One thing people wanted
when we asked them was a hearing service. In
our community more than 80 per cent of the
population is of retirement age so it was a good
service to offer."
CPD Reflect • Plan • Act • Evaluate
Tips for your CPD entry on eye and earcare
REFLECT Are my patients using OTC eye
and earcare products
PLAN Review my knowledge and staff
ACT Read this article, revise minor
eye and ear ailments and
update staff training
EVALUATE Do my patients get good advice
on minor eye and earcare
ailments and how to self-treat?
NASH PHARMACY, ST ALBANS
Director of the Nash Group Amin Bandali has overseen the
development of a hearing laboratory at one of its pharmacies in
The pharmacy group joined forces with a hearing aid audiologist to start
up the hearing laboratory, which offers free hearing tests. The service
generates income through hearing aids and accessories sold to patients.
Mr Bandali says: "We offer free hearing tests to the elderly and our
audiologist fixes their hearing aids for a small fee when they come to us,
so we offer a complete service."
He suggests promoting any service offered through local GPs, and maintaining a strong relationship
with them. He says: "We sent posters, brochures and leaflets to our local CP surgery and they are very
supportive and let their patients know about us."
MIDCOUNTIES CO-OPERATIVE PHARMACY, WALSALL
Pit IIIIL WILKES
Pharmacy manager Phil Wilkes shares his tips for boosting eyecare
"One of the biggest changes in recent years has been the availability of
chloramphenicol in the pharmacy. Obviously we can't keep it in the
pharmacy as it has to go in the dispensary fridge, but since we have had
signs out in the pharmacy, customers have known it is there. That is
something we sell well.
"We have increased sales by promoting products when they were the
focus of television campaigns, and also by using seasonal promotions like putting eye drops with
"When I first saw Optrex Actimist spray I thought it would never sell for £15 a bottle, but it did when
we promoted it around what was being advertised on television."
E# HYPROMELLOSE 0.3% UNIT DOSE
Dry eyes solutions from Moorfields Pharmaceuticals
Available on prescription
(j( j) MOORFIELDS
22 Chemist-Druggist 05.06.10
More Category Focus articles
For: Dry eye relief
glycol 400 0.4 per
glycol 0.3 per cent
USP: Upon contact with the eye forms a gel-
like barrier, according to the manfacturer.
Tel: 0800 092 4567
Format/pack size: 10ml bottle; 28 x 0.8ml
single dose vials
Pip code: 303-8965; 041-4052
RRP: £6.85; £6.85
| y MOORFIELDS
For: Treatment of
H^piomclloic eye drop: 3% BP «
superficial infections of
the external auditory
canal, such as otitis
For: Relief of mild to
externa (swimmer's ear)
moderate dry eyes
glacial acetic acid
Hypromellose 0.3 per cent
2 per cent
USP: EarCalm is the
In December, Moorfields launched a
only branded OTC
dedicated website for pharmacists on the
product for treating
diagnosis and treatment of dry eye syndrome.
outer ear infections,
according to the
Tel: 0207 684 9090
Tel: 01202 780558
Format/pack size: 30 x 0.4ml
Pip code: 349-0174
Format/pack size: 5ml spray bottle
Pip code: 264-8996
Care Olive Oil Eardrops
Manufacturer: Thornton & Ross
Classification: Medical device; available on prescription
For: Softening and removal of earwax
Launched last year,
Tel: 01484 842217
Format/pack size: 10ml bottle
Pip code: 346-7768
Manufacturer: Dendron |g
Classification: P |£
For: Earwax softening
Active ingredients: Urea
hydrogen peroxide 5 per cent
What's new? Otex has a 39 per cent share of the earcare market (IMS,
September 2009) and will be supported by TV activity throughout the
year, the manufacturer says.
Tel: 01923 205706
for Healthy Eyes
VITAMIN & MINElUfc
^ 1 SPECIALLY
TO HELP CARE
FOR YOUR EYES
30 TABLETS ,
For further information please contact us:
Tel: 020 8426 3400
05.06.10 Chemist Druggist 21
Format/pack size: 8ml drops; 10ml 'Express' drops; 10ml 'Express
combi pack' with bulb syringe
Pip code: 205-2330; 334-5501; 345-3305
RRP: £4.65; £4.95; £7.95
17 Blood tests: pt 1 'H 19 Arthritis meds 20 Eye and earcare W 24 New Nice rules f 26 Time planning
10THINGSYOU NEED TO KNOW ABOUT...
Following the publication by Nice of the first national guidelines for childhood
constipation. Gavin Atkin explains what you need to know
Constipation in children is rarely sinister, but sufferers can
experience social, psychological and educational problems that
often require prolonged support. Early identification and
treatment improves outcomes and reduces the demand on
GPs diagnose idiopathic constipation by excluding underlying
causes, and by carrying out a physical examination to establish
whether the child has impacted faeces in his or her colon.
This must be cleared before the child can be prescribed
Although dietary intervention alone is not recommended as a
first-line treatment, parents should be given advice on diet,
fluid intake and exercise appropriate to the child's age and
development. Parents should adopt a positive approach and
encourage their child to take time to go to the toilet. This can be
done for example by scheduling times to do so, recording the
child's movements in a diary, and rewarding the child
appropriately when they use the toilet. A cows' milk exclusion
diet should only be started on the advice of a specialist.
A stimulant laxative should be added if polyethylene glycol
3350 with electrolytes does not lead to disimpaction after two
weeks. Parents should be told the treatment can initially
increase symptoms of soiling and abdominal pain. A stimulant
laxative, on its own or in combination with an osmotic laxative
such as lactulose, may be used if the initial treatment is not
tolerated. See the Nice guidance for full doses.
Maintenance therapy should be started using polyethylene
glycol 3350 with electrolytes as soon as the patient's bowel is
no longer impacted; the suggested dose is about half the dose
used in disimpaction, and is likely to be adjusted according to
the symptoms and response. A stimulant laxative may be
added if the initial treatment is not effective, and lactulose or
docusate may be used if stools are hard.
Once the impacted material has been cleared, maintenance
treatment using laxatives should be prescribed to help the child
establish a regular bowel habit. This may take months, and
during this time the child should be examined frequently to
make sure faecal impaction does not become re-established.
Appropriate laxative doses are essential to relieve faecal
impaction, says Nice. Many of the doses given in the guidelines
are not as given in the British National Formulary for Children
and/or outside the product licence, and informed consent must
therefore be obtained.
During treatment for faecal impaction the child must be
followed up within one week to ensure the treatment is
working. Nice recommends paediatric formula polyethylene
glycol 3350 with electrolytes (polyethylene glycol 3350
6.563g; sodium bicarbonate 89.3mg; sodium chloride 175. 4mg;
potassium chloride 25.1mg) as first-line treatment. The sachets
can be mixed with a cold drink.
For disimpaction in children under one the dose should be half
to one sachet daily; children aged one to five should receive two
sachets on the first day, then four sachets daily for two days,
then six sachets daily for two days, then eight daily; and
children aged five to 12 should receive four sachets on the first
day, increased in steps of two sachets daily to a maximum of 12
daily. The Nice guidance includes separate dosing instructions
for the adult formula treatment and for other laxatives.
Medication at the maintenance dose should be continued for
several weeks after regular bowel habit has become
established. Treatment should not be stopped abruptly, and the
dose should be gradually reduced over a period of months in
response to stool consistency and frequency. Some patients
may require laxative therapy for several years or longer.
For references go to:
CPD Reflect • Plan • Act • Evaluate
Tips for your CPD entry on childhood constipation
REFLECT Is my knowledge of treating childhood
Read about the latest guidelines
Read the C+D guide and Nice's new guidance
EVALUATE Am I confident in advising on childhood
24 Chen ruggist 05.06.10
over 14,720 applications since launch
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Booking and copy date Contact: Andrew Walker Chemist+Druggist
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Runcorn, Cheshire WA7 3DJ. Or email: firstname.lastname@example.org
Closing Date: Monday 21 June 2010. p»
NO AGENCIES PLEASE
HEALTH CENTRE PHARMACY
We are looking for an enthusiastic full time dispenser/
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health centre pharmacy. Training will be provided if needed.
The ideal candidate will be working closely with the complete
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Please apply with a CV. to Beran Patel at 020 8689 7127
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141 Brigstock Road
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Enthusiastic Pharmacists required to manage and provide the full range
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Send your CV by email: email@example.com
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NO AGENCIES PLEASE
jlAa.L"Ln3.(:V L co,L[
/ FULL TIME DISPENSER V
REQUIRED (NVQ LEVEL 2 OR 3)
FOR A BUSY INDEPENDENT 100 HOUR PHARMACY IN
APPLICANT MUST BE MOTIVATED, ENTHUSIASTIC,
CUSTOMER FRIENDLY AND HARD WORKING.
TO APPLY PLEASE SEND CV AND COVERING LETTER
TO:- WORKSOP PHARMACY, 5 POTTER STREET,
WORKSOP, NOTTINGHAMSHIRE. S80 2AD. OR E-MAIL
A TO WORKSOPPHARMACY@YAHOO.CO.UK f
(^excellent + benefits + relocation)Fantastic
opportunities at heart of Community pharmacy.
Email your CV to
or call on 02476 432983
CLINICAL BUSINESS CLI
17 Blood tests: pt 1 ^ 19 Arthritis meds 4 20 Eye and earcare si 24 New Nice rules
26 Time planning
Kelly Mooney (pictured) of
Lloydspharmacy's Irvine, Ayrshire
branch shares her top tips for
time management with Jennifer
"I took a sample week and every
single day I wrote down everything I
did. At the end of the week, I
skimmed out all of the tasks I didn't
need to do. Some of them went in
the bin, others I delegated to other
people, so that I was just doing the
tasks that only I was qualified to do.
I managed to free up half an hour
each Friday to sit down with my
"When we took on a second prison
contract at the branch there was
quite a lot of extra work to fit in, so
I started a weekly planner board -
like a big jigsaw puzzle. I use it to
work out who's the best person to
do each job."
Ms Mooney has found that
challenging established processes in
the pharmacy - mostly simple
scheduling changes such as the time
prescriptions are picked up from the
surgery - has created better
workflow. Consider why you're doing
things, who's best-placed to do them
and when, she advises.
As well as charts to keep everybody
updated on how major tasks are
progressing, Ms Mooney holds
regular team meetings to discuss
what's working and how things
can be improved. "We'll try
something for a couple of weeks
and then discuss whether or not it
works for everyone," she says, "so
we're continually trying to
Beat the clock
A few time management skills can make a big difference in easing
the pressures of the day, writes Chris Chapman
If there's one thing most
pharmacists want, it's more
time. Life in the dispensary
means there often seems to be
too much to cram in - be it
prescriptions, phone calls, sourcing
stock or hitting MUR targets.
There is no easy solution to a busy
workload. However, investing a little
time in a few time management
tricks can make a huge difference in
keeping your head above water.
Good organisation is all about
planning ahead. Consider what you
need to do: what is your end goal?
Once you've established your aim,
think about what you need to do to
achieve this Map out the steps in
order, and break up the target into
smaller, manageable, chunks. For
example, if you're trying to hit 400
MURs, start small - set yourself a
target of 10, then 50, then 100.
Make sure the goal is something you
can measure at the end, so you can
see how you're doing.
The next step is to apply a
timeframe for achieving each goal.
It's important that you make this
realistic - say, 10 MURs in a week
and a half, and 100 within three
months. Now, as long as you check
your list and see how you're doing,
you shouldn't find yourself in a
desperate scramble to complete a
project all in one go. When you
complete a task, cross it off the list.
And planning your time isn't just
useful for achieving long-term aims.
Try mapping out the tasks you need
to do on a weekly chart, making sure
that you've assigned a reasonable
amount of time for each activity.
This will make sure you keep smaller
jobs on your radar, and that you
don't get swamped by taking on too
many jobs in too small a timeframe.
But what if you've just got too much
to do? You need to prioritise. But are
you prioritising the right things? It's
easy to put off a hard task in favour
of something that's not important
but far more enjoyable, leaving more
pressing jobs to the last minute.
Fortunately, there are a couple of
So much to do, so little time: could better time management free you up?
tricks you can use to see what's
important and what you can do
without. One of the most popular is
the Eisenhower method - named
after the US president and general
who is said to have used it.
Draw a graph, with 'importance'
on the x axis and 'urgency' on
the y axis. Turn the graph into four
equal boxes - important/urgent,
important/not urgent, not
important/urgent, and not
Now write a list of all the things
you do on a typical day. Try to cover
everything, from answering the phone
and rearranging shelves to checking
prescriptions and making cups of tea.
Assign each task a number from
one to 10 in terms of importance.
Then go through the tasks again,
assigning it a number from one to 10
in terms of urgency. Now, map these
into the boxes you've created.
You should have a couple of tasks
in the important/urgent box - such
as dispensing prescriptions. These
are the tasks you need to do as a
priority. And again, once the task is
completed, cross it off your list.
There will also be a cluster in the
important/not urgent box, such as
hitting your MUR target or sending a
report. You don't need to do these
immediately, so concentrate on
getting the important/urgent tasks
out of the way. Break the important/
not urgent tasks up into manageable
and measurable stages as before.
Tasks in the not important/urgent
box need dealing with quickly - such
as answering the phone, or checking
the stock order. But ask yourself if
it's you who needs to do it; maybe it
can be delegated?
For tasks that are not important
or urgent, consider dropping them
altogether, or using them to reward
yourself for getting an important
taskoutofthe way if you enjoy them
In a nutshell, time management is
about planning ahead and prioritising.
There is no foolproof method -
problems are always going to crop
up that will demand your attention.
But just by putting a few tactics into
practice, you can make a real
difference to staying on track.
CPD Reflect • Plan • Act • Evaluate
Tips for your CPD entry on time management
REFLECT Do I manage my time effectively?
PLAN Consider whether the methods in this article could help me
better manage my time
ACT Implement methods
EVALUATE Do I feel more in control of my workload and do I have
more time to spend on patient care?
26 Chemist+Druggist 05.06.10
Having trouble finding the right staff?
0207 921 8123
Contact: Andrew Walker
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Springboard is a pre-registration programme offered by Medway School
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05.06.10 Chemist-Druggist 27
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Got a story for Postscript?
the invalid. "Mercy!"
soliloquised the doctor,
"I hope no poor man
has found it."
Recently, a colleague shared a few splendid
examples of medical humour, which I feel
compelled to deliver to a wider audience.
"Do you believe in ghosts?" asked a lady of
one of our celebrated surgeons. "I should be
sorry to believe in them, madam," was the
reply. "Sorry! And why?" asked the lady.
"Because if I did," rejoined the surgeon, "I
should never dare to practise my profession."
Our friend J. is the picture of health, but he
is somewhat nervous when his liver gets at all
out of sorts. He went to consult a physician.
"What do you chiefly complain of?" asked Mr
D. "I have lost my appetite," answered the
invalid, in a voice which almost made the
windows rattle. "Mercy!" soliloquised the
doctor; "I hope no poor man has found it."
Chambers' Journal tells the story of a
student who underwent an examination in
medical jurisprudence. "Pray sir," said the
examiner, "what is a poisonous dose of
prussic acid?" The student replied with
promptitude, "Half an ounce, sir!" Horrified
at the ignorance of the candidate, the
examiner exclaimed, "Half an ounce! Why, sir,
that would poison a community, not to speak
of an individual!" "Well sir," replied the
student, "I only thought I'd be on the safe side
when you asked a poisonous dose!"
It was no laughing matter (despite best
attempts) with this column of medical
jokes, published in C+D in 1883.
Fortunately medical humour has
moved on in the intervening 127 years.
Do you know a good - and clean -
medical joke? The Victorian Pharmacist
clearly doesn't. Share yours at
A star pupil
Middlesbrough pharmacist Michael Maguire
(pictured above) went back to school last month
when he scooped an Alumni Enterprise Award
from the University of Sunderland.
Mr Maguire, who graduated from the uni in
1988, received the accolade for his work in
delivering health initiatives to his local
community, including everything from smoking
cessation and weight management services to
chiropody and acupuncture.
If running his Marton Pharmacy wasn't enough,
Mr Maguire has also founded the groups 'Love
Middlesbrough' and 'Love Health', aiming to boost
the negative image of the Tees town and improve
public health in the area.
Mr Maguire described winning the award from
his old university as a "real honour". "It motivates
me to push the boundaries of pharmacy even
further," he added.
Mr Maguire adds the gong to a trophy cabinet
that also includes a C+D Award, after he won the
Community Pharmacist of the Year accolade at
last year's bash.
• Who is C+D's Community Pharmacist of the
Year 2010? Find out in next week's C+D.
Postscript is a bit nifty when it comes to pub
quizzes (probably because we spend too much
time in pubs), and happened to come across two
trivia gems related to pharmacy last week.
Rather than keep them to ourselves, we
thought a challenge was in order, so get your
brains in gear and see if you know the following:
1. Which figure, famous for being a bit unpopular,
is buried in the garden opposite RPSGB
headquarters in Lambeth?
2. What connects June 1 with the current
If you need a clue, both questions have a
maritime bent. The quiz is just for fun, and
answers will be posted next week. If you can't
wait, check out @CandDChris on Twitter -the
spoilsport has already revealed the solutions.
Z+D reader of the week
Meet Bobby Mehta, football fan, radio DJ and pharmacy
~~ manager for Rowlands Pharmacy's Farnnam branch
If you were not a pharmacist, what would you
be? That's interesting. I work part-time as a radio
DJ, and do Sunrise radio from 7-9pm on Saturdays
and Sundays. So I think I'd be a full-time DJ.
What's the most memorable thing you were
taught at university? How to make copper
sulphate suppositories. I've never had to do it!
What was the point of learning that?
What's the strangest request you've ever had?
Someone came in and asked if we sold cigarettes.
We just looked at them as if they were mad.
Would you recommend pharmacy as a career?
Yeah, there's a lot happening. It's not just a single
facet profession - there's something for everyone.
Do you have a hidden talent? I'm a qualified FA
football coach. I still play - I've got a slipped disc
and have had three knee operations, but I can still
If you had a time machine, where would you
go? To the 2005 Champions League Final, when
Liverpool beat AC Milan [on penalties after coming
back to level the match at 3-3]. It was an
incredible match, I'd love to have been there. Can
you imagine how many people left at half time?
What question should we ask the next
person? If you could offer any new service in your
pharmacy, what would it be?
Calling all pharmacists and technicians. We
want you to be our reader of the week. Email
us at firstname.lastname@example.org
30 C hemist+Druggist 05.06.10
Two new courses
for pharmacy staff
New starter? Want to get them off to a good start but
without having to put them onto a medicines counter
assistant's course straight away?
Counterstart is an induction course for new pharmacy counter staff that will equip
them with the basic knowledge required to work in a pharmacy safely
The course covers:
• My pharmacy and the pharmacy team
® Customer service
• Privacy supported by
• Safety at work
• Selling medicines safely Reckitt
Dealing with prescriptions. Betickiser
Induciion couise for ph
For just £15 (ex. VAT) you can ensure your new staff have a basic training -
plus you can save £5 on their medicine counter assistant's course
Do you want your counter staff to process dispensary
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Stockcheck is an RPSGB accredited dispensary stock management course for
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Different types of medicines
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© Storing stock safely.
C+D Dispensary Stock
For just £40 (ex. VAT) you can ensure your pharmacy staff are fully trained
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For more information go to
or call 0207 921 8425
prefer it over Beconase® and Flixonase® 23 . Give them Nasacort and help avoid problems
whenever hayfever's around. For more information about Nasacort Allergy, and copies
of training materials and point-of-sale items, please contact your local Laser Healthcare
Pharmacy Business Manager or call 01 202 780558.
Contains triamcinolone acetonide
fays where it's sprayed
SORT ALLERGY NASAL SPRAY (TRIAMCINOLONE ACETONIDE) PRESCRIBING INFORMATION
mtation: 20 mi bottle, providing 30 actuations containing 55mcg triamcinolone acetonide per
metered dose. Indications: Treatment of the symptoms of seasonal allergic rhinitis. Dosage and
" ' linistration: Patients aged 18 years and over: The recommended dose is 220 micrograms as
s in each nostril once daily. Once symptoms are controlled patients can be maintained on
ams (1 spray in each nostril once daily). The minimum effective dose should be used to
lued control of symptoms. Medical advice should be sought if symptoms worsen or persist
s treatment. Contraindications: Hypersensitivity to the active substance or excipients,
the nose. Precautions and Warnings: If adrenal function may be impaired, take care
hen transferring patients from systemic steroids. Localised infections of the nose and pharynx with
Candida albicans has rarely occurred. Following, recent nasal surgery or recent prolonged nose bleeds
r any other nasal problems patients should consult their doctor before use. Treatment with high doses
nay cause adrenaj suppression Not recommended under 18 years. Not to be used for longer than 3
bnths' without consulting a doctor. Interactions: No interactions known. Pregnancy and Lactation:
inistered during pregnancy or lactation unless therapeutic benefits outweigh the
oetus/baby. Adverse Reactions: The most commonly reported adverse reactions
e' and pharyngitis. Respiratory disorders: epistaxis, nasal irritation, dry mucous
us congestion and sneezing; rarely, nasal septal perforations. In clinical trials
ons with the exception of epistaxis, were reported at approximately the same or
placebo treated patients. Skin or subcutaneous disorders: rarely allergic reactions
including rash, urticaria, pruritus and facial oedema. Systemic effects of nasal corticosteroids may
occur, particularly when prescribed at high doses for prolonged periods. Retail Price: 30 metered
dose bottle: £4.95 Legal Category: P. Marketing Authorisation Number: PL 04425/0605. Refer
to Summary of Product Characteristics for full prescribing information. Further information
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aventis, One Onslow Street, Guildford, GU1 4YS. Tel. 01483 505515. Date of Revision of Prescribing
Information: April 201 0.
Information about adverse event reporting can be found on
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to the sanofi-aventis drug safety department on 01483 505515.
References: 1. Nasacort Summary of Product Characteristics, October 2008. 2. Lumry W et al.
A comparison of once-daily triamcinolone acetonide aqueous and twice-daily beclomethasone
dipropionate aqueous nasal sprays in the treatment of seasonal allergic rhinitis. Allergy Asthma Proc
2003;24(3):203-10. 3. Stokes M et al. Evaluation of patients' preferences for triamcinolone acetonide
aqueous, fluticasone propionate, and mometasone furoate nasal sprays in patients with allergic rhinitis.
Otolaryngol Head Neck Surg 2004; 131(3):225-231.
PIP code 342-5501. SdDOfi QVefltiS
ation: April 2010. GB.TRM.1 0.04.01